Hindawi Publishing Corporation Case Reports in Oncological Medicine Volume 2016, Article ID 7953745, 4 pages http://dx.doi.org/10.1155/2016/7953745

Case Report Synchronous Diagnosis of Multiple Myeloma, Breast Cancer, and Monoclonal B-Cell Lymphocytosis on Initial Presentation

A. Vennepureddy,1 V. Motilal Nehru,1 Y. Liu,2 F. Mohammad,3 andJ.P.Atallah3

1 Department of Internal Medicine, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA 2Department of Pathology, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA 3Division of and Oncology, Staten Island University Hospital, 475 Seaview Avenue, Staten Island, NY 10305, USA

Correspondence should be addressed to A. Vennepureddy; [email protected]

Received 20 December 2015; Accepted 24 April 2016

Academic Editor: Su Ming Tan

Copyright © 2016 A. Vennepureddy et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

The cooccurrence of more than one oncologic illness in a patient can present a diagnostic challenge. Here we report an unusual case of concomitant existence of multiple myeloma, breast cancer, and monoclonal B-cell lymphocytosis on initial presentation. The challenge was to accurately diagnose each disease and stage in order to maximize the therapeutic regimen to achieve cure/remission. Successful management of the patient and increased life expectancy can be achieved by multidisciplinary management and patient- oriented approach in multiple primary malignant synchronous tumors.

1. Introduction different patterns of MPMs should be considered. Thera- peutically, a multidisciplinary and patient-oriented approach Multiple primary malignant tumors (MPMTs) are rarely should be considered. observed in clinical practice; however, certain fundamental factors for the potential etiology have been described in the literature, including the environment and behavior (tobacco, 2. Case Report occupation, pollution, and ultraviolet light), genetic predis- A 77-year-old female with history of hypertension, diabetes position (Li-Fraumeni or Beckwith-Wiedemann syndromes), mellitus type II, dyslipidemia, and chronic kidney disease previous medical treatment (radiotherapy or chemotherapy), and complex interaction between all these factors [1]. The stageIIpresentedtoourhospitalafterafallinitiallysuspected association between varying cancer types can be classified to be secondary to mechanical factors without any loss of into two categories, which are dependent on the timing of consciousness. Her lab tests on admission were found to be their discovery. An American review stated that the tumors as follows: hemoglobin of 10.8 g/dL (baseline was 12.5 g/dL) with red cell indices within normal limits, white blood are synchronous when the cancers occur at the same time 9 cell count of 9.8 × 10 cells/L with absolute or within 2 months of each other, whereas metachronous 9 tumors occur when the cancers follow in sequence more count of 1.4 × 10 cells/L, absolute granulocyte count of 9 than 2 months apart [2]. The majority of MPMTs that occur 7. 8 × 10 cells/L, and normal platelets. Her serum creatinine in multiple organs are metachronous, while the presence of was 2.01 (baseline was 1.03) with a GFR of 29 and normal synchronous lesions is less common, and in accordance with serum electrolytes. The patient’s initial trauma workup and the behavior of malignancy lesions, these tumors are more physical exam revealed a palpable mass in the upper outer frequent with aging. quadrantoftheleftbreastandmultiplelyticlesionsonC2 This distinction implies important diagnostic and ther- and C5 vertebral bodies and T2 spinous process on the apeutic challenges. From a diagnostic point of view the computerized tomography (CT) scan. Subsequent magnetic 2 Case Reports in Oncological Medicine

(a) (b) (c) (d)

Figure 1: Colloid carcinoma of the breast. This invasive ducal carcinoma exhibits dominant mucin production and tumor cells are arranged in clusters and nests, floating in pools of extracellular mucin (a). Tumor cells are uniform in size and shape with hyperchromatic nuclei without prominent nucleoli and mitosis (b). PR (c) and ER (d) are positive in tumor cells. [(a) H&E, ×100; (b) H&E, ×400; (c) IHC, ×100; (d) IHC, ×100.]

Kappa Lambda

CD138 Cytokeratin

(a) (b)

Figure 2: Photomicrographs from femur bone biopsy (a) and bone marrow clot preparation (b) showing a monomorphic population of plasma cells intermixed with few small and other hematopoietic cells in the bone marrow. The plasma cells show mature cytological features with strong CD138 reactivity and restriction for kappa light chain. No morphologic evidence of carcinoma is identified in both specimens and staining with cytokeratin marker is negative. [(a) H&E, ×100; (b) H&E, ×400.] resonance imaging (MRI) noncontrast of the brain and cer- was done by serum and urine electrophoresis, serum and vical spine exhibited multiple focal lesions of the calvarium, urine immunofixation, and free light chain ratio. The results clivus, C2 and C5 vertebral bodies, and T1 spinous process revealed abnormal IgA kappa monoclonal protein with ele- and cord compression of C3-C4, C4-C5, C5-C6, and C6-C7 vated free light chain ratio. The patient’s subsequent bone suggestive of metastatic disease. The patient was started on marrow biopsy confirmed the diagnosis of MM but also dexamethasone while undergoing malignancy workup. She revealed a minute monoclonal B-cell population with typi- then underwent a nuclear medicine bone scan of the whole cal chronic lymphocytic (CLL)/small lymphocytic body which showed multiple bony abnormalities in the left (SLL) phenotype confirmed via femoral shaft, left acetabulum, L1, L2, and multiple bilateral (Figure 2). ribs consistent with metastatic disease. The patient improved significantly with the supportive The patient’s mammogram and left breast ultrasound treatment and was discharged from the hospital with outpa- showed a 7.5 × 3.7 × 7.8 cm heterogeneous irregularly shaped tient follow-up. The patient was then started on REVLIMID mass at the 2:00 position, 15 cm from the nipple on the and Decadron for MM and pertuzumab, trastuzumab, and upper outer quadrant of the left breast. Subsequent biopsy letrozole for invasive ductal carcinoma of the breast. She ofthemassrevealedaninvasivewelldifferentiatedductal underwent positron emission tomography (PET-CT) as part carcinoma with mucinous features (colloid carcinoma) (Fig- of the initial treatment workup as well as for determining ure 1). The breast cancer proved to be triple positive for the appropriate site for bone biopsy to differentiate between estrogen, progesterone receptors, and HER2 via immunohis- metastatic breast cancer and MM as MM lesions usually tochemistry and fluorescence in situ hybridization testing. do not light up on the bone scan. The PET-CT revealed a The lytic lesions on bone scan were initially suspected tobe fluorodeoxyglucose (FDG) avid 4.3 × 5.1 cm partially calcified of metastatic breast cancer. leftbreastmass(SUV3.2)aswellasincreaseduptake(SUV The combination of acute kidney injury, normocytic 4.3) in the 5.3 × 4.3 cm lytic lesion of the right distal femur. normochromic anemia, and multiple bony lesions was sus- The right femur and left pubic bone were biopsied which pected of being multiple myeloma (MM) and its workup showed only monomorphic population of plasmacytoid cells Case Reports in Oncological Medicine 3 consistent with plasma cell neoplasm with no evidence of 4. Conclusion metastatic breast cancer (Figure 2). The patient is currently continuing the neoadjuvant In summary, here we presented a case of synchronous diagno- chemotherapy with pertuzumab, trastuzumab, and letrozole sis of MM, breast cancer, and monoclonal B-cell lymphocyto- while awaiting surgical evaluation for the triple positive sis on initial presentation. The diagnosis of dual malignancy localized left breast cancer and REVLIMID and Decadron for in a patient at the time of the first presentation is rare. We symptomatic multiple myeloma. She is also being monitored initially suspected the lytic lesions on bone scan could be for the progression of the CLL/SLL clone. from metastatic breast cancer but were found out to be only localized breast cancer with pure myelomatous involvement Synchronous diagnosis of two different primaries is very of bony lesions. This made the patient undergo mastectomy important as the management of these coexisting malignan- alongwithcontinuationofneoadjuvantchemotherapy.The cies is different. In our case report, we initially thought the patient also needs to be monitored for any development of lytic lesions could be from metastatic breast cancer which CLL from monoclonal B-cell lymphocytosis. Recognizing in turn proved to be pure myelomatous involvement of both malignancies at the time of presentation and before bone and no signs of metastases from breast cancer which initiation of treatment is crucial since the management of changed the management and made the patient undergo these coexisting malignancies is different. mastectomy. This patient should also be monitored for any In conclusion, successful patient’s management and evidence of development of CLL as we found monoclonal B- increased life expectancy can be achieved by multidisci- cell population with typical CLL/SLL phenotypic picture on plinary management and patient-oriented approach in mul- flow cytometry of bone marrow biopsy. tiple primary malignant synchronous tumors.

3. Discussion Disclosure Primary soft tissue extramedullary is uncom- The authors stipulate that all persons listed as authors have mon and is defined as a malignant tumor of plasma cells contributed to preparing of the manuscript and that no per- arisinginthesofttissueintheabsenceofboneinvolvement. son or persons other than the authors listed have contributed It can occur in any organ as a solitary form of plasma significantly in its preparation. cell neoplasm [3]. Breast plasmacytoma is one of the major differential diagnoses in synchronous diagnosis of breast Competing Interests cancer and multiple myeloma as may mimic breast cancer in some cases, especially when axillary lymph The authors declare the absence of any commercial or nodes are involved. Few case reports have been published in other associations that might pose competing interests in the literature where breast plasmacytomas can occur either connection with the submitted paper. as a solitary lesion without evidence of systemic disease [4– 7] or concurrently with multiple myeloma [8–11] or as a sign References of relapse in patients with known history of myeloma [12– 15]. [1] F. Rabbani, G. Grimaldi, and P. Russo, “Multiple primary To the best of our knowledge, few case reports have malignancies in renal cell carcinoma,” Journal of Urology,vol. been described in the literature with synchronous diagnosis 160, no. 4, pp. 1255–1259, 1998. of multiple myeloma and breast cancer. Cao et al. reported [2]H.L.Howe,“Areviewofthedefinitionformultipleprimary a case of breast tumor where infiltrating ductal carcinoma cancers in the united states,” in Workshop Proceedings From of the breast and breast plasmacytoma occurred which December 4–6, 2002, North American Association of Central was coexistent in the breast tumor on initial presentation Cancer Registries, Princeton, NJ, USA, May 2003. and the patient got successfully treated with chemotherapy [3] C. Van Nieuwkoop, R. W. M. Giard, H. F. Veen, and A. Dees, forbreastcancerandradiotherapyforplasmacytoma[16]. “Extramedullary plasmacytoma of the breast simulating breast cancer,” Netherlands Journal of Medicine,vol.58,no.4,pp.174– Khalbuss et al. reported a case of synchronous diagnosis 176, 2001. of multiple myeloma and breast cancer with plasmacytoid [4] C. W. Cutler, “Plasma-cell tumor of the breast with metastases,” morphology on initial presentation [17]. This case illus- Annals of Surgery,vol.100,no.2,pp.392–394,1934. trated the deceptive cytomorphologic similarities between [5]J.InnesandJ.Newall,“Myelomatosis,”The Lancet,vol.277,no. an epithelial malignancy and a hematopoietic malignancy. 7171, pp. 239–245, 1961. Since myeloma plasma cells vary from mature forms to [6]N.S.F.Proctor,J.J.Rippey,G.Shulman,andC.Cohen, pleomorphic, anaplastic plasma cells, they can easily mimic “Extramedullary plasmacytoma of the breast,” Journal of Pathol- the cytomorphology of adenocarcinoma and vice versa. The ogy,vol.116,no.2,pp.97–100,1975. distinction may be challenging by cytomorphology alone [7]T.J.Bloomberg,J.P.Glees,andJ.E.Williams,“Bilateralbreast [17].Kherfanietal.reportedacaseofspinalcordcompression lumps: an unusual feature of extramedullary plasmacytoma,” from concurrent multiple myeloma and metastatic breast British Journal of Radiology,vol.53,no.629,pp.498–501,1980. cancer in the same vertebra [18]. Al-Said Ali et al. reported [8] B. Rosenberg, J. N. Attie, and H. L. Mandelbaum, “Breast tumor synchronous diagnosis of multiple myeloma and breast can- as the presenting sign of multiple myeloma,” The New England cer on initial presentation similar to our case in 2009 [19]. Journal of Medicine,vol.269,pp.359–361,1963. 4 Case Reports in Oncological Medicine

[9] K. Maeda, C. M. Abesamis, L. M. Kuhn, and B. H. Hyun, “Multiple myeloma in childhood: report of a case with breast tumors as a presenting manifestation,” American Journal of Clinical Pathology,vol.60,no.4,pp.552–558,1973. [10] W. B. Bassett and R. B. Weiss, “Plasmacytomas of the breast: an unusual manifestation of multiple myeloma,” Southern Medical Journal,vol.72,no.11,pp.1492–1494,1979. [11] A. Ben-Yehuda, D. Steiner-Saltz, E. Libson, and A. Polliack, “Plasmacytoma of the breast—unusual initial presentation of myeloma: report of two cases and review of the literature,” Blut, vol.58,no.3,pp.169–170,1989. [12] I. L. Craft, “The late appearance of extramedullary lesions in myelomatosis,” British Journal of Cancer,vol.21,no.3,pp.501– 504, 1967. [13] A. Mangalik and P. K. Gupta, “Soft tissue involvement in plasmacytoma and multiple myeloma: a report of seven cases,” Indian Journal of Pathology and Microbiology,vol.17,no.1,pp. 45–51, 1974. [14] J. S. Ross, T. M. King, J. I. Spector, H. Zimbler, and R. M. Basile, “Plasmacytoma of the breast. An unusual case of recurrent myeloma,” Archives of Internal Medicine,vol.147,no.10,pp. 1838–1840, 1987. [15] C. Lombardi, A. Calvi, E. Bonera, A. Savio, and E. Savio, “Bilateral breast involvement in a 71-year-old white man with lambda light chain disease. Regression after a new chemother- apy combination. A case report,” Tumori,vol.78,no.1,pp.35– 36, 1992. [16] S. Cao, H.-G. Kang, Y.-X. Liu, and X.-B. Ren, “Synchronous infiltrating ductal carcinoma and primary extramedullary plas- macytoma of the breast,” World Journal of Surgical Oncology, vol. 7, article 43, 2009. [17]W.E.Khalbuss,G.Fischer,M.Ahmad,andB.Villas,“Syn- chronous presentation of breast carcinoma with plasmacytoid cytomorphology and multiple myeloma,” Breast Journal,vol.12, no. 2, pp. 165–167, 2006. [18] A. Kherfani, K. Amri, M. Hachem, L. Abid, M. Bouaziz, and M. Mestiri, “An association of vertebral breast cancer metastasis and multiple myeloma, revealed by a spinal cord compression,” Pan African Medical Journal,vol.19,article168,2014. [19] A. Al-Said Ali, I. Al-Bader, F. Al-Ali, A. H. Elgazzar, and S. Fayez, “Breast cancer and multiple myeloma at initial presen- tation,” Breast Journal, vol. 15, no. 1, pp. 103–105, 2009. M EDIATORSof INFLAMMATION

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